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Published Date:05/03/2019

Printed Date:9/22/2015

URL:http://palmgba.com/marlowe/redesign6/article.html

CPT Modifier 26

Description:
Professional component

Guidelines/Instructions:

CPT modifier 26 designates the service as "interpretation only" and is most commonly submitted with diagnostic tests, including radiological procedures

Refer to the Medicare Physician Fee Schedule database (MPFSDB) to determine if CPT modifier 26 is applicable to a particular procedure code

This modifier must be submitted in the first modifier field

Steps:

Access the Fee Schedule database on the Palmetto GBA website

Indicator

Description

0

Physician service codes. This indicator identifies codes that cannot be separated into professional and technical components. Examples include visits, consultations and surgical procedures. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Neither CPT modifier 26 nor HCPCS modifier TC can be submitted with these codes.

1

Diagnostic tests or radiology services. This indicator identifies codes that describe diagnostic tests (e.g., pulmonary function tests) or therapeutic radiology procedures (e.g., radiation therapy). These codes generally have both a professional and technical component CPT modifier 26 and HCPCS modifier TC may be submitted with these codes.

2

Professional component only codes. This indicator identifies stand-alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test only and another associated code that describes the global test. An example of a professional component only code is CPT code 93010: Electrocardiogram; interpretation and report. Neither CPT modifier 26 nor HCPCS modifier TC can be submitted with these codes.

3

Technical component only codes. This indicator identifies stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic test only. An example of a technical component only code is CPT code 93005: Electrocardiogram; tracing only, without interpretation and report. It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code. Neither CPT modifier 26 nor HCPCS modifier TC can be submitted with these codes.

4

Global test only codes. This indicator identifies stand-alone codes for which there are associated codes that describe (a) the professional component of the test only and (b) the technical component of the test only. Neither CPT modifier 26 nor HCPCS modifier TC can be submitted with these codes.

5

Incident to codes. This indicator identifies codes that describe services covered incident to a physician's service when they are provided by auxiliary personnel employed by the physician or working under his or her direct supervision. Payment will not be made for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. Neither CPT modifier 26 nor HCPCS modifier TC can be submitted with these codes. For more information on 'incident to' guidelines, refer to CMS Pub. 100-02, Chapter 15, Section 60 (PDF, 1.36 MB).

7

Physician therapy service. Payment may not be made if the service is provided to a hospital outpatient or inpatient by an independently practicing physical or occupational therapist.

8

Physician interpretation codes. This indicator identifies the professional component of clinical laboratory codes for which separate payment may only be made if the physician interprets an abnormal smear for a hospital inpatient. This applies only to CPT code 85060. No technical component submission is recognized because payment for the underlying clinical laboratory test is made to the hospital. Note: no payment is made for CPT code 85060 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test.

9

Concept of a professional/technical component does not apply.

Reference:

Complete definitions of supervision indicators are available in CMS Pub. 100-04, Chapter 23 (PDF, 1.83 MB), in the Addendum following Section 90

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